Provider Demographics
NPI:1023421633
Name:ZUCCARELLI, JORDAN (DPT)
Entity type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:
Last Name:ZUCCARELLI
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 E IRON AVE
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-2634
Mailing Address - Country:US
Mailing Address - Phone:785-764-0497
Mailing Address - Fax:785-746-0428
Practice Address - Street 1:405 E IRON AVE
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-2634
Practice Address - Country:US
Practice Address - Phone:785-764-0497
Practice Address - Fax:785-746-0428
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-04804225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201101340AMedicaid
KS255000004Medicare PIN